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SAN. ,QUIN COUNTY PUBLIC HEALTH SER ES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRE <br />TANK ID ##39 D TANK SIZE: /?9i G'Cn PREVIOUS TANK CONTENTS: G456It-e- <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: ��ri �" ��,! ,00d✓City: ZOS /'1340d5' Zip: <br />Phone 1#: Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor <br />�5 `-� r e% <br />Address: �/� Fa" City <br />Phone ##: () O�g'/5—/z) <br />LPs B •*o,5 <br />Zip: <br />Authorized representative of contractor certifying through signature below that the tanjr6A bee n ated in an approved <br />manner as required by Cal EPA. <br />Name: �ar�'�/���� Title: _4i,�% Signa l' Date % <br />*********************************************************************************************************** <br />/�- <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: ct;�,C-,o y4eg4.<,5 7 r>i;Z� City: `;54l -r-5 <br />Phone t# : ((.0 (-Q I) 399 - g 5 5 (.o <br />Date Tank Received: 01 ). m) 9 Q <br />Zip: j ��j/2 <br />Name:�02R1 C ANN m£Lv IL -Lt, Title:SyS * SCHP_Du, � N (o Signa <br />0'7 C� c7 I <br />EH 23 046 (Revised 10/19/98) Page 10 <br />